New Client Intake Form
Please help us get to know you and your pet!
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Secondary Phone Number
Please enter a valid phone number.
E-mail
*
example@example.com
Is there someone else who should be authorized to make decisions for your pet?
First Name
Last Name
Secondary Contact's Phone Number
Please enter a valid phone number.
What is their relation to you?
How did you hear about us?
*
Please Select
Internet/Google
Driving By/Sign
Emergency Clinic
Yellow Pages
Facebook
Other (Please specify...)
Other
*
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Please tell us all about your pet
We can't wait to meet them!
Name:
*
What sort of pet do you have?
Canine
Feline
Breed:
*
Colour:
*
When is your pet's birthday?
*
-
Month
-
Day
Year
*It's OK if you don't know the exact date
What sex is your pet?
*
Male
Female
Neutered Male
Spayed Female
What is the name of the clinic where your pet was last examined?
*
If this file could be under someone else's name, please let us know!
Does your pet have any known allergies?
Have something you want to show us? Add it here!
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Social Media Release
I grant CAMPBELLVILLE ANIMAL HOSPITAL full permission to use any and all images taken of my pets for the sole use of education, advertising, and promotion. This includes but is not limited to photographic prints and products, cds, dvds, Facebook, Twitter, YouTube, Instagram and other social media sites, website blogs, and website display.
I agree to the above statement:
Yes
No
Have a second pet? Click here to add their information!
Name
What sort of pet do you have?
Canine
Feline
Breed
Colour
When is your pet's birthday?
-
Month
-
Day
Year
*It's OK if you don't know the exact date
What sex is your pet?
Male
Female
Neutered Male
Spayed Female
What is the name of the clinic where your pet was last examined?
If this file could be under someone else's name, please let us know!
Does your pet have any known allergies?
Have another pet, add them by clicking here!
Name
What sort of pet do you have?
Canine
Feline
Breed
Colour
When is your pet's birthday?
-
Month
-
Day
Year
*It's OK if you don't know the exact date
What sex is your pet?
Male
Female
Neutered Male
Spayed Female
What is the name of the clinic where your pet was last examined?
If this file could be under someone else's name, please let us know!
Does your pet have any known allergies?
Back
Next
Why is your pet coming for an appointment today?
What changes have you noticed in your pet’s personality or behaviors?
*
Please rate your pet's itchiness
*
Please Select
1
2
3
4
5
6
7
8
9
10
Score from 1-10, 1 being not itchy at all, 10 being extremely itchy
Stool Quality Score
*
Please Select
1
2
3
4
5
Score from 1-5, 1 being profuse diarrhea, 5 being extremely hard
Does your pet... (your opinion)
*
Drink too much water
Drink the right amount of water
Not drink enough water
Is your pet peeing more than usual?
*
Yes
No
Have there been any recent accidents in the house?
*
Yes
No
Does your pet attend grooming/boarding/daycare/dog park facilities?
*
Yes
No
Does your pet hunt?
*
Yes
No
Does your pet roam freely outdoors?
*
Yes
No
Does your pet eat feces/drinks outdoor water from wildlife/other pets/its own?
*
Yes
No
Do you camp with your pet?
*
Yes
No
Was your pet living in or traveling with you to heartworm/tick endemic area in the last 12 months? (USA, Southwest/Northern Ontario)?
*
Yes
No
Was your pet on heartworm prevention last summer from June until November?
*
Yes
No
When was the last dose of flea/tick and or heartworm prevention given?
-
Month
-
Day
Year
Date
Does your pet have a history of vaccination reaction?
*
Yes
No
What diet is your pet currently eating?
*
Please note canned and dry food
Please upload pictures of any food, treats, medications or supplements your pet is currently taking:
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Already have a cute picture of your pet? Upload it here!
File Upload
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Did we forget something?
Please list any questions/problems/concerns that you would like addressed
Thank you for answering all of our questions, it helps us to deliver a more thorough and comprehensive experience for you and your pet!
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